Example Document Reference - Encounter-based

This document reference example represents a document from a patient consultation with the adult diabetes service that has been captured as an Encounter in the patient record. The patient was seen by a nurse and a dietitian, who both authored content within the document. The document was finalised and approved by the consultant with overall responsibility for the patient's care. The document content is signposted by a url to the location from which the document PDF can be retrieved for display.

NOTE that the example is illustrative of DocumentReference content in the case that an Encounter exists. That Encounter holds the document metadata items that relate to the event such as event location and senior responsible clinician. Not all of the referenced resources currently exist as examples within this implementation guide.

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DocumentReference
DocumentReference.id[0]Example-DataStandardsWales-DocumentReference-EncounterBased
DocumentReference.meta[0].source[0]urn:oid:2.16.840.1.113883.2.1.8.1.5.210
DocumentReference.meta[0].profile[0]https://fhir.nhs.wales/StructureDefinition/DataStandardsWales-DocumentReference
DocumentReference.meta[0].tag[0].system[0]seqno
DocumentReference.meta[0].tag[0].display[0]1
DocumentReference.meta[0].tag[1].system[0]docattr_documenttypecode
DocumentReference.meta[0].tag[1].display[0]CONSULTATIONNOTE_DIABETES
DocumentReference.meta[0].tag[2].system[0]docattr_documentsubtype
DocumentReference.meta[0].tag[2].display[0]Adult services
DocumentReference.meta[0].tag[3].system[0]docattr_clonesequencenumber
DocumentReference.meta[0].tag[3].display[0]0
DocumentReference.meta[0].tag[4].system[0]docattr_thirdpartydataincluded
DocumentReference.meta[0].tag[4].display[0]True
DocumentReference.extension[0].url[0]https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentDigitalStatus
DocumentReference.extension[0].value[0]born-digital-document
DocumentReference.extension[1].url[0]http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.version
DocumentReference.extension[1].value[0]1
DocumentReference.extension[2].extension[0].url[0]mode
DocumentReference.extension[2].extension[0].value[0].coding[0].system[0]https://hl7.org/fhir/valueset-composition-attestation-mode.html
DocumentReference.extension[2].extension[0].value[0].coding[0].code[0]professional
DocumentReference.extension[2].extension[0].value[0].coding[0].display[0]Professional
DocumentReference.extension[2].extension[1].url[0]time
DocumentReference.extension[2].extension[1].value[0]2025-07-22T13:09:37+00:00
DocumentReference.extension[2].extension[2].url[0]party
DocumentReference.extension[2].extension[2].value[0].reference[0]PractitionerRole/Example-DSW-PractitionerRole-Consultant-JoeBloggs-HDUHB
DocumentReference.extension[2].extension[2].value[0].display[0]BLOGGS, Joe A, Dr (GMC:1234567), Consultant Diabetologist for HDUHB
DocumentReference.extension[2].url[0]http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.attester
DocumentReference.identifier[0].system[0]https://fhir.nhs.wales/Id/wcrs-document-identifier
DocumentReference.identifier[0].value[0]FF849C81-9917-47D9-B929-4AF1BDD94670
DocumentReference.identifier[1].system[0]https://fhir.nhs.wales/Id/wcrs-supersession-set-identifier
DocumentReference.identifier[1].value[0]6DB699D2-AD58-43DD-AEA5-341AE3DBFF93
DocumentReference.status[0]current
DocumentReference.docStatus[0]final
DocumentReference.type[0].coding[0].system[0]http://snomed.info/sct
DocumentReference.type[0].coding[0].code[0]766841000000106
DocumentReference.type[0].coding[0].display[0]Consultation with patient
DocumentReference.category[0].coding[0].system[0]http://snomed.info/sct
DocumentReference.category[0].coding[0].code[0]325931000000109
DocumentReference.category[0].coding[0].display[0]Assessment
DocumentReference.subject[0].reference[0]Patient/Example-DataStandardsWales-Patient-HaroldJames
DocumentReference.subject[0].display[0]JAMES, Harold A, Mr
DocumentReference.date[0]2025-07-22T11:20:17+00:00
DocumentReference.author[0].reference[0]PractitionerRole/Example-DSW-PractitionerRole-Nurse-EmilyMay-HDUHB
DocumentReference.author[0].display[0]MAY, Emily B, Ms (NMC:AB12345X), Nurse for HDUHB
DocumentReference.author[1].reference[0]PractitionerRole/Example-DSW-PractitionerRole-Dietitian-JudeFrancis-HDUHB
DocumentReference.author[1].display[0]FRANCIS Jude, Miss (HCPC:DT123456), Dietitian for HDUHB
DocumentReference.custodian[0].reference[0]Organization/Example-DataStandardsWales-Organization-HDUHB
DocumentReference.custodian[0].display[0]Hywel Dda University Health Board
DocumentReference.description[0]Diabetes Consultation Note
DocumentReference.securityLabel[0].coding[0].system[0]http://terminology.hl7.org/CodeSystem/v3-Confidentiality
DocumentReference.securityLabel[0].coding[0].code[0]N
DocumentReference.securityLabel[0].coding[0].display[0]Normal
DocumentReference.content[0].attachment[0].contentType[0]application/pdf
DocumentReference.content[0].attachment[0].language[0]eng
DocumentReference.content[0].attachment[0].url[0]https://www.example.com/documentref1234
DocumentReference.context[0].encounter[0].reference[0]Encounter/Example-DSW-Encounter-DocumentedEvent-DiabetesConsultation
DocumentReference.context[0].practiceSetting[0].coding[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-PracticeSettingCode
DocumentReference.context[0].practiceSetting[0].coding[0].code[0]302
DocumentReference.context[0].practiceSetting[0].coding[0].display[0]Endocrinology and Diabetes
<DocumentReference xmlns="http://hl7.org/fhir">
<id value="Example-DataStandardsWales-DocumentReference-EncounterBased" />
<meta>
<source value="urn:oid:2.16.840.1.113883.2.1.8.1.5.210" />
<profile value="https://fhir.nhs.wales/StructureDefinition/DataStandardsWales-DocumentReference" />
<tag>
<system value="seqno" />
<display value="1" />
</tag>
<tag>
<system value="docattr_documenttypecode" />
<display value="CONSULTATIONNOTE_DIABETES" />
</tag>
<tag>
<system value="docattr_documentsubtype" />
<display value="Adult services" />
</tag>
<tag>
<system value="docattr_clonesequencenumber" />
<display value="0" />
</tag>
<tag>
<system value="docattr_thirdpartydataincluded" />
<display value="True" />
</tag>
</meta>
<extension url="https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentDigitalStatus">
<valueCode value="born-digital-document" />
</extension>
<extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.version">
<valueString value="1" />
</extension>
<extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.attester">
<extension url="mode">
<valueCodeableConcept>
<coding>
<system value="https://hl7.org/fhir/valueset-composition-attestation-mode.html" />
<code value="professional" />
<display value="Professional" />
</coding>
</valueCodeableConcept>
</extension>
<extension url="time">
<valueDateTime value="2025-07-22T13:09:37+00:00" />
</extension>
<extension url="party">
<valueReference>
<reference value="PractitionerRole/Example-DSW-PractitionerRole-Consultant-JoeBloggs-HDUHB" />
<display value="BLOGGS, Joe A, Dr (GMC:1234567), Consultant Diabetologist for HDUHB" />
</valueReference>
</extension>
</extension>
<identifier>
<system value="https://fhir.nhs.wales/Id/wcrs-document-identifier" />
<value value="FF849C81-9917-47D9-B929-4AF1BDD94670" />
</identifier>
<identifier>
<system value="https://fhir.nhs.wales/Id/wcrs-supersession-set-identifier" />
<value value="6DB699D2-AD58-43DD-AEA5-341AE3DBFF93" />
</identifier>
<status value="current" />
<docStatus value="final" />
<type>
<coding>
<system value="http://snomed.info/sct" />
<code value="766841000000106" />
<display value="Consultation with patient" />
</coding>
</type>
<category>
<coding>
<system value="http://snomed.info/sct" />
<code value="325931000000109" />
<display value="Assessment" />
</coding>
</category>
<subject>
<reference value="Patient/Example-DataStandardsWales-Patient-HaroldJames" />
<display value="JAMES, Harold A, Mr" />
</subject>
<date value="2025-07-22T11:20:17+00:00" />
<author>
<reference value="PractitionerRole/Example-DSW-PractitionerRole-Nurse-EmilyMay-HDUHB" />
<display value="MAY, Emily B, Ms (NMC:AB12345X), Nurse for HDUHB" />
</author>
<author>
<reference value="PractitionerRole/Example-DSW-PractitionerRole-Dietitian-JudeFrancis-HDUHB" />
<display value="FRANCIS Jude, Miss (HCPC:DT123456), Dietitian for HDUHB" />
</author>
<custodian>
<reference value="Organization/Example-DataStandardsWales-Organization-HDUHB" />
<display value="Hywel Dda University Health Board" />
</custodian>
<description value="Diabetes Consultation Note" />
<securityLabel>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality" />
<code value="N" />
<display value="Normal" />
</coding>
</securityLabel>
<content>
<attachment>
<contentType value="application/pdf" />
<language value="eng" />
<url value="https://www.example.com/documentref1234" />
</attachment>
</content>
<context>
<encounter>
<reference value="Encounter/Example-DSW-Encounter-DocumentedEvent-DiabetesConsultation" />
</encounter>
<practiceSetting>
<coding>
<system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-PracticeSettingCode" />
<code value="302" />
<display value="Endocrinology and Diabetes" />
</coding>
</practiceSetting>
</context>
</DocumentReference>
{
"resourceType": "DocumentReference",
"id": "Example-DataStandardsWales-DocumentReference-EncounterBased",
"meta": {
"source": "urn:oid:2.16.840.1.113883.2.1.8.1.5.210",
"profile": [
"https://fhir.nhs.wales/StructureDefinition/DataStandardsWales-DocumentReference"
],
"tag": [
{
"system": "seqno",
"display": "1"
},
{
"system": "docattr_documenttypecode",
"display": "CONSULTATIONNOTE_DIABETES"
},
{
"system": "docattr_documentsubtype",
"display": "Adult services"
},
{
"system": "docattr_clonesequencenumber",
"display": "0"
},
{
"system": "docattr_thirdpartydataincluded",
"display": "True"
}
]
},
"extension": [
{
"url": "https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentDigitalStatus",
"valueCode": "born-digital-document"
},
{
"url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.version",
"valueString": "1"
},
{
"extension": [
{
"url": "mode",
"valueCodeableConcept": {
"coding": [
{
"system": "https://hl7.org/fhir/valueset-composition-attestation-mode.html",
"code": "professional",
"display": "Professional"
}
]
}
},
{
"url": "time",
"valueDateTime": "2025-07-22T13:09:37+00:00"
},
{
"url": "party",
"valueReference": {
"reference": "PractitionerRole/Example-DSW-PractitionerRole-Consultant-JoeBloggs-HDUHB",
"display": "BLOGGS, Joe A, Dr (GMC:1234567), Consultant Diabetologist for HDUHB"
}
}
],
"url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.attester"
}
],
"identifier": [
{
"system": "https://fhir.nhs.wales/Id/wcrs-document-identifier",
"value": "FF849C81-9917-47D9-B929-4AF1BDD94670"
},
{
"system": "https://fhir.nhs.wales/Id/wcrs-supersession-set-identifier",
"value": "6DB699D2-AD58-43DD-AEA5-341AE3DBFF93"
}
],
"status": "current",
"docStatus": "final",
"type": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "766841000000106",
"display": "Consultation with patient"
}
]
},
"category": [
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "325931000000109",
"display": "Assessment"
}
]
}
],
"subject": {
"reference": "Patient/Example-DataStandardsWales-Patient-HaroldJames",
"display": "JAMES, Harold A, Mr"
},
"date": "2025-07-22T11:20:17+00:00",
"author": [
{
"reference": "PractitionerRole/Example-DSW-PractitionerRole-Nurse-EmilyMay-HDUHB",
"display": "MAY, Emily B, Ms (NMC:AB12345X), Nurse for HDUHB"
},
{
"reference": "PractitionerRole/Example-DSW-PractitionerRole-Dietitian-JudeFrancis-HDUHB",
"display": "FRANCIS Jude, Miss (HCPC:DT123456), Dietitian for HDUHB"
}
],
"custodian": {
"reference": "Organization/Example-DataStandardsWales-Organization-HDUHB",
"display": "Hywel Dda University Health Board"
},
"description": "Diabetes Consultation Note",
"securityLabel": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
"code": "N",
"display": "Normal"
}
]
}
],
"content": [
{
"attachment": {
"contentType": "application/pdf",
"language": "eng",
"url": "https://www.example.com/documentref1234"
}
}
],
"context": {
"encounter": [
{
"reference": "Encounter/Example-DSW-Encounter-DocumentedEvent-DiabetesConsultation"
}
],
"practiceSetting": {
"coding": [
{
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-PracticeSettingCode",
"code": "302",
"display": "Endocrinology and Diabetes"
}
]
}
}
}